Sprains

Question 1

Health History Questions?

Answer 1

1. What is your overall health?
2. Do you have any contributing conditions or pathologies that predispose you to ligament injuries?
3. Is there a history of injury or recurrent sprains of this joint?
4. When did the current injury occur?
5. Do you know the mechanism of injury?
6. Did you hear any noise at the time of the injury?
7. What was done at the time of injury? Was first aid applied?
8. Were you able to continue with activity after the sprain?
9. Have you seen any other health care practitioner for this injury?
10. Are you taking any medication for the sprain?
11. Have you been using any supports or crutches for the affected joint?
12. Were there any complications with the sprain?
13. What aggravates and/or relieves the pain?
14. Is any swelling or any edema present local or distal to the injury?
15. With a sprain of a weight bearing joint, does the joint “give way”?
16. What activities are difficult or painful to complete?
17. What are you ADL’s?

Question 2

Contraindications?

Answer 2

1. In the acute stage, testing other than pain-free AF ROM is CI’d to prevent further tissue damage?
2. Avoid removing the protective muscle splinting of acute sprains?
3. Distal circulation techniques are CI’d in the acute and early subacute stages to avoid increasing congestion through the injury site?
4. With Grade 3 sprains that are casted, avoid hot hydrotherapy applications to the tissue immediately proximal to the cast to prevent congestion under the cast?
5. With Grade 3 sprains where the ligaments have been surgically repaired, do not restore full ROM of the affected joint in the direction that will stretch the repaired ligament
6. Frictions are CI’d if the client is taking anti-inflammatories or blood thinners

Question 3

Treatment
Acute?

Answer 3

1. The injury is treated with RICE
2. Positioning depends on the location of the sprain and the client’s comfort
3. Hydrotherapy is cold such as an ice pack applied to the injured area
4. Reduce edema on the injured limb
5. Maintain local circulation proximal to the injury only
6. Reduce but do not remove protective muscle spasm
7. Maintain ROM with mid-range PR ROM on the proximal joints
8. Treat secondary conditions

Question 4

Treatment
Early Subacute?

Answer 4

1. The limb is elevated
2. Hydrotherapy applications on site are cold/warm
3. Reduce edema proximal to the injury site
4. Maintain local circulation proximal to the injury site
   Reduce protective muscle spasms
5. Reduce trigger points in muscles that refer to the injured limb and the injury site itself is now treated
6. Maintain ROM with mid-range passive relaxed ROM
7. Distal techniques of light stroking and muscle squeezing are used

Question 5

Treatment
Late Subacute

Answer 5

1. The limb is elevated
2. Hydrotherapy local to the injury are cold/hot. If acute inflammation recurs, the therapist returns to using local cold hydrotherapy
3. Reduce any remaining edema
4. Reduce HT and TPs in proximal limb and muscles that refer to the injured limb and the injury site itself
5. Reduce adhesions by applying stripping, petrissage and frictions to the ligament and surrounding structures
6. After the ligament has been frictioned, joint play and pain-free passive stretching is used to realign the fibres, followed by ice
7. Gradually increase ROM with pain-free mid-range PR ROM
8. Increase local circulation and distally to the injury site

Question 6

Treatment
Chronic

Answer 6

1. Positioning is chosen for client comfort and accessibility of the structures being treated
2. Hydrotherapy applications proximal to the sprain and on the lesion site include deep moist heat
3. Reduce any chronic pockets of edema that remain
4. Reduce HT and TPs proximal to the injury site
5. Reduce adhesions by applying stripping, petrissage and frictions to the ligament and surrounding structures
6. Restore ROM with PR ROM on the proximal, affected and distal joints to maintain joint health
7. Increase local circulation distal to the injury site

Question 7

Treatment
If the Limb is Immobilized

Answer 7

1. Once immobilization is removed and if the sprain was medically treated using casting, the joint is likely unstable in the direction the sprain occurred
2. Because the ligament wasn’t surgically repaired, there is little to prevent hypermobility other that the support given by the muscles that cross the joint
3. In this case, mobilization techniques are CI’d and instead, remedial exercises are created to strengthen the muscles that cross the injured ligament
4. If the ligament was surgically reduced, rendering the joint stable, the ligament has been repaired in a shortened position. Because ligaments are non contractile, this repair is done to allow the client to stretch the joint capsule to a functional range without allowing hypermobility to occurs

Question 8

Self-Care

Answer 8

1. Hydrotherapy is chosen for the stage of healing. Since ligaments are hypovascular, it is important to introduce contrast as soon as possible
2. Self-massage for the muscles that cross the sprained joint in the subacute and chronic stages
3. Remedial exercise is given dependent on the stage of healing
4. Pain-free AF ROM of the proximal and distal joints in the acute stage
5. Submaximal, pain-free isometric exercises to strengthen the muscles that cross the sprained joint
6. Pain-free AF ROM of the affected and distal joints in the early subacute stage
7. Re-educate proprioception, especially in weight bearing joints as soon as possible
8. Increased strength and ROM is gradually increased in the late subacute stage with pain-free AR isometric exercise
9. AR isotonic exercises to strengthen the muscles that cross the affected joint are performed in the chronic stage
10. If tight muscles prevent normal ROM at the affected joint, stretching is carefully performed to maintain these ranges
11. The client is encouraged to return to the ADLs on a gradual basis

Question 9

Classifications of Sprains

Grade 1

Answer 9

Grade 1: Mild or First Degree Sprain

1. Minor stretch and tear to the ligament
2. No instability on passive relaxed testing
3. The person can continue activity with some discomfort

Question 10

Classifications of Sprains

Grade 2

Answer 10

Grade 2: Moderate or Second Degree Sprain

1. Tearing of the ligament fibres occurs
2. The degree of tear is quite variable from several fibres to the majority of the fibres
3. There is a snapping sound at the time of injury and the joint gives way
4. The joint is hypermobile yet stable on passive relaxed testing
5. The person has difficulty continuing activity due to pain

Question 11

Classifications of Sprains

Grade 3

Answer 11

Grade 3: Severe or Third Degree Sprain

1. Either a complete rupture of the ligament itself or an avulsion fracture as the bony attachment of the ligament is torn off while the ligament remains intact
2. There is a snapping sound and the joint gives way
3. There is significant instability with no end point on passive relaxed testing
4. The person cannot continue activity due to pain and instability

Question 12

Joint Effusion

Answer 12

Joint Effusion:

1. Occurs when the injury is severe enough to inflame the synovium, increasing the production of synovial fluid and causing the joint capsule to swell
2. Effusion is primarily composed of synovial fluid and is intracapsular
3. Hemarthrosis, or bleeding into the synovial space may also happen
4. Edema occurs in the extracapsular interstitial spaces as a result of the inflammatory process and is composed of inflammatory exudate

Question 13

Ligaments

Answer 13

Ligaments:

1. Are moderately vascularized and therefore, heal slowly
2. Adhesions form between the sprained ligament and nearby structures, painfully limiting the ROM controlled by the ligament
3. Scar tissue in the ligaments takes up to six weeks to develop, however, it takes a full six months for scar tissue to completely mature and provide maxim strength at the affected joint
4. Ligaments in Grade 3 sprains may be surgically repaired or treated by the medical approach of immobilizing the joint in a cast or strapping

Question 14

Symptom Picture-Acute

Answer 14

Grade 1:

There is a minor stretch to the ligament

Pain is mild and is local to the injury site at rest and on activity that stresses the ligament

Minimal local edema, heat and bruising present
Joint is stable

Client can continue activity

Grade 2:

Tearing of some or many fibres of the ligament

Snapping noise and the joint gives way

Pain is moderate at rest and with activities that stress the ligament

Moderate local edema, heat and bruising are present

Joint instability, if present, is slight

Difficulty continuing the activity due to pain

Grade 3:

A complete rupture of the ligament or an avulsion fracture of the ligament attachment

A snapping noise
Pain may be intense or mild at rest

Marked local edema, heat and bruising

Hematoma may be present, joint effusion may occur

Joint is unstable
Client cannot continue activity

In all grades of sprain
Bruising is red, black and blue

Decreased ROM local to the joint as protective muscle spasm, edema and pain limit movement

Depending on the severity, there is little, moderate, or severe loss of function of the affected joint

A strain or contusion of the muscles crossing the joint, vascular damage or nerve complications are possible

Question 15

Note

Answer 15

• acute: start:

+ Slightly elevated, rest, ice, compression
+lymphatic technique —> reduce edema
+ light distal work, onsite work is CI
+ relaxation back, unaffected side & treat compensatory

• early subacute:

+ position —> elevate
+ start with lymphatic drainage
+ treat unaffected & compensate structures—> work proximal to injury and light distal work
+ reduce muscle spasms : GTO relieve
+ TP’s in referring muscle—> quads/ hamstrings ( for ankle sprain)
+ cold hydro

Late subacute:

+
+ stripping
+ friction
+ ROM increasing —> never force to stretch in direction of drama
+ use more resisted isometric

Chronic:
+ TP’s
+ X fibre frictions
+ joint play ( as long as not stretching the direction that strain )
+ fully work on any direction
+ can use heat
+ use ice after friction

Homecare: (board homecare requirements):

+ ADL change
+ hydro
+ stretch
+ strength

Question 16

TX goals:

Answer 16

• Acute:

+ reduce P
+ reduce edema
+ increase circulation
+ reduce protective muscle spasms ( do not remove)
+ maintain ROM

• Subacute:

+ reduce pain
+ reduce edema
+ reduce SNS
+ reduce muscle spasms
+ increase or maintain circulation
+ reduce TP
+ maintain ROM or increase ROM
+ reduce adhesions

• chronic:

+ reduce SNS
+ reduce edema
+ reduce HT + TP
+ reduce adhesion
+ increase ROM
+ increase circulation
+ strengthen muscle crossing joint

Question 17

Common Sprains

Answer 17

I. Lateral Ankle:

1. Anterior talofibular ligament:

The most frequently sprained lateral ankle ligament

2. Calcaneofibular ligament:

Second most commonly sprained lateral ankle ligament

3. Calcaneocuboid ligament:

Less frequently injured

The most common mechanism of injury is an inversion sprain where the ankle is forcefully inverted, damaging ligaments on the lateral side of the joint

II. Medial ankle:

Deltoid Ligament:

Quite strong and is more common for the attachment at the tibia to avulse than for the ligament itself to

An eversion sprain where the ankle is forced into eversion is less usual

III. Knee:

1. Medial & Lateral Collateral Ligaments:

Medial collateral ligament is most frequently injured, often when the foot is fixed to the ground and the knee is struck by a medially directed or valgus force

A laterally directed or varus force of the knee causes a lateral collateral sprain that is less common

The collateral ligaments are extracapsular and therefore, massage therapy can directly treat them

2. Anterior & Posterior Cruciate Ligaments:

Anterior cruciate is injured when the tibia is forced anteriorly, usually when the person is weight bearing through the leg

Posterior cruciate is injured if the tibia is pushed posteriorly

The cruciates are deep within the joint and are not directly accessible to massage techniques

These ligaments are often surgically repaired

IV. Wrist:

1. Palmar radiocarpal

Most common mechanism of injury to the wrist is forced hyperextension

Palmar radiocarpal ligaments are quite strong and therefore unlikely to be sprained in isolation

Usually accompanying this type of sprain is damage to the flexor muscles and tendons and the bones of the wrist

2. Dorsal radiocarpal ligament:

May be damaged with a forced hyperflexion injury, possibly in association with injury to the extensor tendons and wrist bones

Weaker than the palmar radiocarpal ligament

V. Shoulder:

Acromioclavicular ligament:

A Grade 1 AC sprain involves tearing of the joint capsule

A Grade 2 AC sprain is classified as a tear of the joint capsule and the AC ligament

A Grade 3 AC sprain involves a tear of the joint capsule, the AC ligament and the conoid and trapezoid ligaments.
A fracture may also be present
The mechanism of injury is usually falling onto the shoulder itself

Question 18